More Testing

Last weekend, I flew to Chicago to take my oral boards. To be board-certified in Emergency Medicine, one must first pass a written exam (woohoo!) and then the oral boards. Oral boards are scheduled twice a year, and there is a lottery system to determine whether or not you get the Spring or Fall test date. Luckily, I drew October, since there was that whole wedding business going on in April.

If you ask me, the concept seems kind of outdated. The oral boards take place in a hotel by the airport, and several floors are rented out. Over a four-hour block, applicants are shuffled around from room to room, and given test cases. Basically, you go into a hotel room and sit down at a card table with a plastic divider set up between you and the examiner. They give you a sheet of paper with a few lines on it, and some vital signs. From there, you have to ask 50 bazillion questions to scratch out a review of systems and physical exam, and respond to the answers given by the examiner. It's like a painful GI-distressing version of "20 Questions" in formal business attire. You are also given x-rays, EKGs and lab results to review on the spot. Each case lasts about 15 minutes and there are a few multi-patient cases that last 30 minutes.

The whole situation is just awkward, from having to wear a suit, to being in hotel rooms, to trying to picture a patient that is not in front of you and respond to them. I feel that it is outdated, as a lot of residency programs (mine included) have Simulation labs, where residents are tested with interactive mannequins that you can do procedures on and respond live to your interventions. I am just not exactly sure what the oral boards are testing. My knowledge base was already tested with the written exam. They can't really test my bedside manner or procedural skills by a on-the-spot dialogue in a hotel room. It seems like they should just get rid of the oral boards or modernize them with Sim testing if they really want to ensure that candidates have been trained equally by their residency programs.

That being said, I do think that the Board does go through a lot of effort to make sure that everyone is fairly tested, from their bizarre scoring system, and all of the examiners were very courteous and professional. All of my patients lived, and I think that I passed, although now I have to wait for three months to get the official results. Even more revealing is that once I am board-certified, I will have to take the written test every 10 years, but never the oral boards again, so I don't really see the point in the whole thing.

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The nice thing about the weekend, is that I did get to see some of my buddies from residency. We went out to dinner together after the test, and then took the train downtown to a piano bar called "Howl at the Moon". It was a fun place, and there were a lot of people there who had just run the Chicago Marathon, and still had energy enough to dance away the night.

Here, for your viewing enjoyment, is a new bride dancing to "All My Exes Live in Texas"... the groom was off drinking in the corner.

Hard Times

Me: "So, the chart says that you cut yourself yesterday?"

Pt: "Yeah."

Me: "Why did you do that? Were you trying to hurt yourself?"

Pt: "Yeah. I thought that if I cut my hand deep enough, you could amputate it, and then I could get disability."

Me: "Do you work now?"

Pt: "No, I'm on disability."

Me: "So the idea was to get more disability?"

Pt: "Yeah."

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No, the hand didn't need to be amputated, it was actually a very minor laceration. I guess the economy is hitting everyone pretty hard right now, even disabled schizophrenics. And for the record, I don't think that you get bonus diability money for further injuries, so don't try that one at home.

Yellow

I looked at the nurse's notes, and there it was:

Chief Complaint: "My skin is all yellow."

I sighed, and pulled back the curtain. 2 am isn't exactly when my peak diagnostic skills are kicking in. To be honest, I think I almost dropped my clipboard when I first saw her. Icteric eyes blinked back at me. There in the stretcher was probably the most jaundiced woman I have ever seen. She was fluorescent yellow, including her scalp.

As we chatted about her medical complaint and history, it was clear that there wasn't going to be a happy outcome- progressive jaundice, abdominal pain, unintentional weight loss. This was all adding up to cancer.

The patient related that she had been seen initially in an urgent care and what started with x-rays led to a referral for a CT scan as an outpatient. She had no private physician-- "I'm healthy." She said that she was told that she had a hiatal hernia and was put on an antacid, but it wasn't helping. In fact, she thought the medicine was making her more yellow and now was giving her itchy skin, so she quit taking it.

I asked her if she had the report, and she handed it over. Sure enough, in tiny print, it mentioned a hiatal hernia. However, just below that, there were several more lines about the existence of multiple masses in the liver, abdomen, pelvis, and spine. I asked her if she was told about the tumors, and she said no, but an appointment had been set up with a local specialist at the end of the month.

I reviewed our labs with her and told her that it didn't look good. I called the hospitalist for admission and ordered a contrast study. I went back to the patient and told her we needed more images to define the tumors better, but it looked like she had widespread cancer and that it was likely too advanced to be treated. I'm not sure where her cancer originated from, but at this point, she will probably just be put on palliative care, or referred to home hospice.

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The way that the woman presented herself from the beginning was kind of bizarre. I feel certain that she must have been told about the tumors, and she had a copy of the report in her hand. I think that she was just in denial, and hoping that her symptoms could be blamed on anything else. She did thank me for letting her know what was going on, I just think that the diagnosis was probably too much for her to process the first time she heard it.

Representing

I am not accustomed to dealing with drug reps. During residency, they were banned from our program by our department chair. Generally speaking, I think that emergency physicians are a much less optimum target for sales than internists or family practitioners. Probably at least 75% of my prescriptions are based on about five different medications. In addition to the fact that I stick with tried-and-true medications, emergency physicians tend to write prescriptions that don't have refills. It is a lot less appealing to get an EM doc to write for a 30-day supply, rather than an internist that's going to write for 365-days worth, and has the potential to renew that prescription year after year.


Anyhow, at the new job, there are drug reps that occasionally drop in. I never know when they are going to be around, and they typically just show up in the break room with food. Apparently, the last time one came while I was working, they were offended that I didn't take time to visit them. I don't really have any interest in looking at brochures or reading about receptors. If your product is not in any of my books, I am not going to write for it. Period.


The last one that I did sit down with, I felt guilty the whole time. There were patients waiting to be seen, but I needed to shove some food in my face anyway, so I figured it might as well be a fresh salad and wrap instead of the standard PB&J I bring to work.


Care to guess what his product was?


It was a reversal agent for narcotic-induced constipation. Yup, for 10 minutes while I crammed food in my mouth and nodded, he went on and on about success rates of inducing bowel movements within an hour's time. I might be a physician, but I don't really want to talk about intestinal transit times WHILE I AM EATING!

Death By Powerpoint

Last week I went through a five-day board prep course. A few of my classmates from residency and I flew out to the Midwest and camped out in a hotel. We endured 50 lecture hours over 5 days! I had forgotten how painful it can be to spend so much time in a lecture hall, and haven't slugged down that much caffeine in a long time. A couple of my classmates from medical school were there as well, although no one that I keep in touch with.

The course itself was pretty thorough. Some of the lectures were interesting, while others weren't really geared to board review. In addition to attending the lectures and following along with the provided notes and daily quizzes, lectures were continually run on one of the TV channels in the hotel rooms. There were also a couple of rooms upstairs that were filled with x-rays and images to quiz yourself on.

The first couple of days were a little overwhelming, but by the end of it, I feel like I had been given enough material. Very little of it was new, but there are a few areas like hemotologic disorders, derm stuff, and random neuro findings I need to focus in on to pick up a few points here and there. The majority of first-time test takers pass the exam, but it is pretty expensive and only offered once a year, so I would like to not repeat the experience if at all possible. Board certification in Emergency Medicine is a two-step process. The second part involves an oral exam that you only get "invited" to take once you pass the written part. After that, there's just some continuing education stuff to keep up with, and recertification isn't for another 10 years.

AG finally gets to come home for his "mid-leave" break in just a few days, and so my plan is to just relax during his leave. Afterwards, I have about a month after he leaves before the exam, so that will be the time to hunker down and really get back into studying.

Teens, Take Note

If you are a teenager, please note that updating your "mood" on MySpace to "suicidal" is not a good idea. You might just end up in my world via police escort. Once you arrive, you get stripped down, and you can lie in a psych room with questionable stains on the wall for hours before the doctor can see your lame ass. And your mom will be very, very pissed.

Adventures in Babysitting

Sometimes, my patients just baffle me with their requests. Such was the case recently, when a pregnant young woman asked if she could be admitted to the hospital because, "All I have for food at home is peanut butter and Goldfish."


She was a young, newly-married Army wife, and the request made me look again at her ID which listed her age as 16. Her medical complaint was easy enough to deal with; both her and the fetus were fine. She hadn't gotten any prenatal care yet, as she said that she didn't have any insurance, which also made me do a double-take given her social situation.


I asked her where her husband was, and it turned out that he was off doing pre-deployment exercises in another state for the next several weeks. During their training, the men are unavailable by phone and the only number she had was his cell phone. I asked her if she had any money at home, and she said that she didn't. Apparently, her husband had taken their only credit card with him.


The more questions I asked, the worse it got.

I asked her who their unit chaplain was, and she didn't know. I asked her what unit her husband was in, and she didn't know. I asked her how she'd gotten to the hospital and it turned out that she had called an ambulance and that she didn't know anyone in the area to come and pick her up. And wouldn't you know it, her husband had left his vehicle behind, but she doesn't even know how to drive. The nurses were also muttering something about her not having any furniture in the apartment and sleeping on the floor, but at that point, I really didn't want to hear any more.


So Social Work got involved, and I ordered the woman/child a dinner tray. They actually contacted the runaway teen hotline because her whole story was kind of bizarre. Typically, the military does a very thorough job at providing resources for family members, particularly wives and children of active duty soldiers. This child just was completely clueless, and without any kind of foresight about providing for herself. In the end, the staff duty officer of the night had to come in and make sure she was set up with insurance, food, and resources. I'm sure that her husband got quite the talking to about the whole thing, but for all I know he's probably barely 18 himself. It was quite the contradiction to see someone with with access to nearly unlimited resources and not enough knowledge to use them. At this rate, I don't know how she's going to make it through the winter.

All Done!

The past two weeks have been a blur. I graduated from my residency program. My parents were here for a week-long visit. An aunt, uncle, and cousin came out for the occasion, along with my older brother and his wife. My classmates and I were roasted in appropriate fashion by the second- and first-year residents. It was a good sendoff. My last two shifts in the department were crazy-busy with very sick patients. My last shift was with my closest friend here, and after staying three hours late to finish up all of our charts, we went out to Denny's to celebrate. As I was getting home from my "4pm - midnight" shift, the sun was coming up.

Some of my classmates I was more than ready to be done working with, and some I was sad to see go. The past three years have flown by so fast that it is sometimes hard to believe how much learning and activity was crammed into them. Despite moonlighting for the past year, I am still nervous about starting my new job, learning and new system, and trying to do my best for my patients without harming them in the process. When I matched here, I wasn't certain what to expect, however I couldn't have been happier with my program. I think that the teaching has been excellent, and I couldn't have asked for better people to work with every day.

I have received my first schedule for my new job, and I am almost flabbergasted by how few hours I will be working compared to what I have been juggling lately. My written board exam is coming up in just a few months, but after that is out of the way, it looks like I might be able to have some semblance of a normal life in the very near future. After four frantic med-school years followed by three years of residency, I am not sure that I'm going to know what to do with myself!

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In regards to the house, it is pretty much sold. I met with my lawyer on Thusday and signed my end of the paperwork with the actual closing scheduled to happen sometime next week.

On Tuesday, the movers packed up the house, and loaded up the truck. Wednesday was unloading day, and the number of boxes crammed into the new place was almost overwhelming. I have been steadily unwrapping and sorting through stuff for the past three days, and only now is starting to look like an actual liveable space rather than a storage room around here.

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Happy 4th of July!

Seven

Seven shifts, that is all that remains of my residency. Part of me is eager for it to be over, and the other part is panicked about not having that safety net of an attending to run things by. There will be a new safety net--specialists to talk to on the phone, skilled nurses and physician assistants who know the in's and out's of my new hospital.

Some things I am happy to leave behind, like dictating a full note after every single patient. Others, like going out for breakfast after an overnight shift, or potlucks with the nurses I'm going to miss. As for my residency classmates, the group of us will probably never be together in the same room again. We are spreading out accross the country, and although right now everyone's promising to return for the wedding next Spring, some of these people whom I have spent so much time with, I will never see or hear from again.

Shifts are longer at my new hospital, but in return there are more days off. And despite being a "community hospital", the volume is practically the same as my current Level 1 Trauma Center. There are less specialists and no residents, which translates into me doing more procedures myself than I do here. I fully anticipate to be stressed this first year out, but it's what I want... I think. Some of my classmates are staying here where they are comfortable, and others have negotiated better contracts for less hours and less patients than I will be seeing. I tend to learn more by doing than reading about it, so I think I would rather struggle now in my career and gain experience and confidence rather than slowing down and maybe having to learn to increase my productivity later in my career.

Island Medicine, Part 1

Our residency program has been sending senior residents down to St. Lucia for several years now. We volunteer in an Emergency Department at a small hospital there and in exchange, they provide us with food and housing. It's a different experience than back home. Resources are limited, and patients must pay for service and medicines up front. Patients pay a fee before they are even seen in the Emergency Department, and then they get billed for any medications dispensed, or supplies used, like gauze and suturing materials. If x-rays are ordered, they have to pay for them before they will be taken and blood tests are paid for before they are drawn.

This was our drug supply cabinet. It was organized by shelf. The third shelf was mostly empty, and was our only cache of antibiotics to work with.

Unfortunately, most of our antibiotic supply was this:

If you look closely, you'll notice that it's expired.

The Emergency Department itself was fairly small, and is one of the only air-conditioned areas in the hospital. There were four curtained off rooms. The big pink chair is the asthma chair, and standing next to it is a large oxygen tank.

The system seems to work well. Most of the patients are in and out fairly quickly. I put on splints, reduced a dislocated shoulder, and did a fair amount of suturing. What we could fix, we fixed, and unfortunately the mortality rate seems to be fairly high. The hospital has a fair amount of specialists- (pediatrics, obstetrics, orthopedics, general surgery) but there's not a whole lot that they can do for things like strokes or heart attacks. I saw one child with chicken pox-- which I haven't actually seen at all during my residency because of the vaccine. Another of my patients had lost a leg due to leprosy.

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There is only one certified paramedic on the island, and unfortunately he was not on any of the ambulances that brought me patients. The ambulances seem to function more like the old hearse system. They are minivans with equipment inside, but for some reason, other than arriving with oxygen, nothing seems to get done for the patients. IVs are not started, medicines are not administered, and sometimes you may not even get a set of vital signs.

My patient with the dislocated shoulder was transfered from a clinic and had gotten nothing for pain. He apparently bit his first ambulance attendant, so they dropped him back off at the clinic and took their attendant to a different hospital for a tetanus injection before returning back to pick him up and bring him in.

Two of my patients were brought in pulseless and apneic (not breathing) and neither one of them had CPR being performed as they arrived. When I asked one of the ambulance dudes why they weren't doing anything, he said that the patient had already had a minute of CPR by a bystander when they arrived, and it didn't help, so he didn't think the patient needed CPR or ventilation apparently! So our codes were pretty futile, but we attempted anyway. There was only one ventilator in the hospital, and it was occupied by some guy with a head injury, so intubation would have meant riding in the ambulance with the patient to a hospital over an hour away and bagging the whole time.

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During our two weeks, the Carifta Games were going on. The Carifta Games are kind of like a Caribbean Olympics for athletes ages 14-20. Several of the athletes eventually go on to compete in the Olympics. The group of residents prior to ours had helped develop a mass-casualty plan for the event with the hospital, and we were there to staff the medical stations. The actual spectator turnout seemed to be a lot less than what was originally anticipated, and the weather was mild. Something like 200 patients were seen over 3 days, but most of it was minor cuts, twisted ankles, nausea, or "Can you just check my blood pressure?" type complaints. I spent most of my day there watching the races and long jump competition.

These stands were in the sun, so they were largely empty. The one behind me probably held a couple thousand people.

If I remember the uniforms right, these two young ladies were from Barbados.

The Jamaican athletes were clobbering all of the other teams, just like in Beijing.

Our favorite thing to do after work in the evening (unfortunately it was dark by 6:30!) was to sit around drinking and playing cards. The hospital sold cases of Piton (local beer) at a discount. If I worked the evening shift, the day was spent hopping on buses and getting myself down to the nearest beach, where the wind was apparently perfect for kite surfing and windsurfing. It was also a great spot to pull up a towel in the shade and relax before work.

My favorite reading spot:

The Steamer

In my line of work, it is important to get along with one's coworkers. Doing shift-work means that we don't stay until the patient is dispositioned. Often a patient gets seen and examined, labs and imaging studies are ordered, and then their care is transferred over to the new doctor when it is time for the original provider to go home. In regards to patient care, this can be the most dangerous time for the patient as the incoming doc typically doesn't have time to fully re-evaluate the patient.

As you can imagine, everyone has their own level of comfort in decision making. After you get to know the other doctors in the group, you can typically figure out who is going to have more patients to sign-out because they tend to order more tests than everyone else, who is going to do very minimal work-ups, and who is going to intentionally order a CT scan fifteen minutes before the end of their shift so that they don't have to make the decision about what to do about the patient during their time in the department.

Like every other job, it's frustrating to get additional work handed over to you by people who seem to be determined to get by doing the bare minimum. It also stinks to come in to a full waiting room and patients who have been in rooms for hours, not seen by anyone, and the previous staff heads home seemingly carefree on-time.

At my place, we've come to refer to bad sign-outs as steamers, because the messes left behind are reminiscent of steaming piles of... well, you get it. Sometimes it's unintentional, but sometimes someone who's billed as "stable" suddenly deteriorates after shift change and it seems to be more a factor of a shoddy exam or workup because someone was in too much of a hurry. Extreme examples of this would be the patient signed out as "possible pneumonia" ending up needing a pelvic exam because their "rib pain" turns out to actually be belly pain, or in one really bad example, a "stable" patient coding in the CT scanner.

After being in a hospital for a while, you get to know how your night's going to start depending on who the previous shift was, and steamers definitely happen at both the attending and the resident level. I think that all of us ultimately want to do right by our patients and co-workers, but when there are so many interruptions in care throughout the shift, it becomes easily to get distracted, especially by the thought of it being past time to go home. It does get old after a while, and I can't imagine what it's like to be in the same place, taking bad sign-outs from the same co-workers over and over, year after year. While the names and faces will be changing out in a few months when I leave, I am sure the situation will be the same.

New Low

The other day I confronted a woman who was seeking pain meds. The medical student saw her first and there were a few things during her presentation that just screamed that this lady was going to be trouble:

1. Abdominal pain x 1 year

2. Recent month-long admission with no diagnosis

3. Multiple abdominal surgeries

4. Allergic to morphine, "Only Dilaudid works"

5. "I need a PICC line, no one can ever get an IV on me."

At first I felt mildy guilty for being cynical, but as the case unfolded, it turned out she had lied to us during the interview. When I had asked if she could be pregnant, she said, "No." When I told her that she was, she said, "Oh yeah, the hospital yesterday said that, too." Her pain had been coming and going for about a year, so there wasn't anything to do emergently besides some basic labs and physical exam.


We got ready to discharge her and she asked for pain meds. As it turned out, she already had a prescription for narcotics from another hospital, but it wasn't very pregnancy-friendly. I don't like talking down to people, but in this case I told her that the only way I would give her a prescription for a pain medicine was if she gave me her other one to destroy. So we traded prescriptions. Let's just hope she doesn't call the other hospital up saying she "lost" their prescription. In the meantime, I've sent a nasty-gram to her primary physician. I will still probably end up with a letter from the Board of Health in a few months letting me know she got multiple prescriptions from different providers, but at least she left my department with a prescription for a safer drug.

Just before discharge, I looked her up in our computer system, and the only thing listed was a previous admission for what turned out to be pseudoseizures and there was a mention of "drug-seeking behavior". When we confronted her, she didn't deny seeking pain meds, but now I wonder if I didn't miss the real diagnosis.

Happy New Year!

Happy New Year! I decided to finish off 2008 by breaking my right pinkie toe. It was stupid-- I was putting away laundry and just managed to stub it hard on the corner of the bed. I've iced it, buddy-taped it, and have been taking ibuprofen when I can remember to. Most of the time, it's fine, but it has caused me to hobble around and try to heel walk on that side at work the last two nights.

Behold, the unhappy piggy (ignore the sad state of my toenail polish):

All in all, 2008 has been a great year: I fell in love, ran a half marathon, had a great Alaskan adventure, and have signed a contract for my first "real" job. My family and friends are doing well, and I really can't complain. Overall, I feel happy and confident, and can't remember the last time that I have had so many things to look forward to.

2009 however, is off to a violent start. I worked the overnight shift, and despite starting out with an empty ED, it was crazy. At midnight we wore party hats and toasted each other with sparkling cider. We potlucked, and waited for the chaos. It finally started at about 1:30. Multiple patients with multiple stabbings, several overdoses, too many head lacerations to count, and every kind of skull fracture/head bleed combo imaginable: depressed fractures, non-depressed fractures, subarachnoid bleeds, subdural bleeds, intraventricular bleeds with impending herniation. That last one is going to turn into the first homicide of the year... our charge nurse was joking at the beginning of the shift that there should be a door prize for the first homicide of the year like there is for the first baby born in a local hospital (yes, we are a dark-humored group).

I spoke with AG this morning, and he sounded in good spirits (although getting tired of lobster, poor boy!).

So here's to 2009: Bring it on!

Santa's Knee

It has been snowing a lot here lately. The snowblower has piled snow up past the the height of the doors of my car on each side. I have a narrow driveway, so there's barely room anymore to drive down between the walls of snow.

The other night I was working in the Pediatric ED, when I happened to glance over at the adult side. There, in room 19, was a man in his 60s wearing a t-shirt that tugged at his beer belly, red suspenders, and blue jeans. His long white hair snaked past his shoulders and he had a full scruffy beard. Both hands were bandaged with gauze and were obviously now reduced to bloody meat as blood was ominously spreading across the dressing. As it turned out, he'd stuck not one, but both hands into his snowblower.

For only a brief second, I thought about grabbing the closest screaming tot and plopping him/her down on Santa's lap. Perhaps AG and I should start with a dog...

Drats

Last week we wrapped up the first arm of our rat study. The study was time consuming, in that I had to drive into work 2-3 times per day to check on them and do testing. It was also interesting in that we learned to develop our protocol along the way. For example, one of the symptoms that we were looking for was renal failure, so we were monitoring urine output. At first, we were going to base this on cage weights, but that seemed too variable. Then we decided to line the cages with an absorbant pad that we could easily glance at for urine output. The rats responded in kind by chewing up the pad to make nesting material. Finally, we had to resort to wire cages with pads below to collect specimens. This, of course, required more paperwork.

This was the control arm of the study, so we were giving the rats a known chemical compound, and then treating them with placebo (saline). The next arm of the study would be administering the same weight-based dose of chemical to a new group of rats, only this time administering a likely antidote with the expectation that there would be less behavioral changes and less cellular damage.

Our dose of toxin was based on an "established" LD50 from other people's research (Being a child of the 80's I'm going to call this O.P.R.). LD50 is short for lethal-dose 50, and means that 50% of subjects receiving that dose should die. This is somewhat variable given that nothing in medicine is exact. From OPR, death or at least renal failure was expected to develop in 3-5 days. Our control arm was 10 days long.

Unfortunately, we ran into a huge problem: NONE of the rats died. There was some weakness noticed with behavior testing and at least one of the rats was doing some odd drunken head-bobbing, but that was about all that we noticed.

Being the suspicious women that we are, we had ordered extra rats in case some of them failed the baseline neuro testing, so we had a few extra rats to work with. On day 6, we gave those extra rats double the LD50 and....

NONE of them died, either!

So now there's a huge problem with our study in that if our chemical compound is not actually toxic at the dose we gave, we can't really proceed with the antidote arm. We have contacted the people behind OPR, and not really gotten anything other than, "hmm, that should have worked." Currently, our tissue samples are with the pathologist, so hopefully there will be some sort of changes at the cellular level, otherwise we have to either ditch the remainder of the study or do another study to first determine the proper LD50.

In trying to figure out what went wrong we've thought of:

1. Maybe our chemical isn't what the label says it is (and it didn't have an expiration date), so we have sent samples to an outside lab for analysis.

2. Maybe by administering saline we prolonged the renal failure and study wasn't long enough to reach our endpoints of renal failure/death.

3. Maybe our math was wrong, but it's been quadruple-checked.

4. OPR was wrong, and we need to do a separate LD50 study.

So there has been a lot of learning with this project. Either way, I have something to present for my required academic project, but I really wanted this to work. There have been a few accidental contaminations in consumer products with this compound, and it would have been cool to be part of the research behind developing a protocol for treating an ingestion. There are still blood tests pending as well, so for now, I am crossing my fingers and trying to be patient.

Busted!

This year I have been moonlighting at one of the community ED's nearby. It's a different type of patient mix-- most of the patients are insured, and maybe it's all in my head, but they seem to be more polite, and actually follow-up with their private physicians. I typically work a shift or two a month for extra money. I don't want to miss any time that I could be spending with AG before he deploys, and to be honest, I really don't want to give up too many of my days off.

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Anyway, the other night, working at two different hospitals came in handy. I was working with my friend, M, and I grabbed the next chart and walked into the room. It was a young woman who was complaining of bilateral knee pain, and told the nurse that she hadn't been able to walk for the past 3 days. When I walked in, I was surprised to recognize the girlfriend of one of my patient's that I had seen the night before in my base hospital. I remembered her because he was there for a big, long rule-out appendicitis workup and she proceeded to hound the nursing staff constantly and paced back and forth across the department making phone calls (and demanding we feed said boyfriend immediately, despite his reported pain and vomiting, once it turned out that he didn't have appendicitis).

So, I called her on it, and she said she hid the difficulty walking the night before because she was concerned about her boyfriend. Fine. I asked her how she got to the hospital that night because when thinking about pain meds, you typically don't want to give a bunch of narcotics to someone who is about to drive home. That's when she said that she walked to the hospital. ???

Hmm, so I now I have someone who wants narcotics (allergic to ibuprofen, and acetaminophen "doesn't work") for an injury that doesn't make any sense. So, I gave her a shot of an anti-inflammatory that she'd never heard of, and sent her on her way. Reportedly, she'd had months of intermittent pains, no trauma/fall, and a normal physical exam, which to me means no need to waste any time with x-rays/imaging.

Just before she walked out to the waiting room, I ask her how the boyfriend's doing, and she says, "His belly doesn't hurt no more, now it's his teeth."

Hmm...

I sit down next to M, and see what he's up to. Wouldn't you know it, he's right in the middle of writing a prescription for narcotics for a young male with dental pain! I tell him the story, and mention how the guy just got discharged from our ED with narcotics the night before.

So, we both walk back to the guy's room, and I just stand there silently while M grills him for not telling him about the prescription he'd just gotten the night before. He doesn't deny anything, and just sheepishly says that he never filled the first one, but that he still has it at home. M tells him to go fill the first script because we're not giving him anything tonight, and out the door he slinks.

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I am sure that this happens all the time, but as I typically work just in one location, I don't see it that much. With electronic tracking, we now can easily look up just how many times someone's been in our department and what they've been given, so it's easy to tell if they have prematurely run out of their pain meds. However, there's no way to link between hospitals, so we can't really tell just how much someone's trying to abuse the system. This couple will probably still continue their quests for meds, but hopefully it will be to hospitals 3, 4, and 5 instead of the two I'm at.

dFwMP

Last night, I happened to glance down the hallway and there they were-- gleaming, copper-colored calf boots with a good 5-inch heel. They belonged to a young woman, and how she managed to walk in them I will never know, but it reminded me of a couple of strange cases that I had recently. In the Emergency Department, it sometimes seems like patients seem to come in clusters with the same injury. One shift it is asthma-day, the next is heart-failure day, etc.

The other week, I had two bizarre high-heel related injuries. The first was a young woman who got clubbed in the face by a stiletto. She had a D-shaped laceration present just below her eye. A few centimeters different, and she would have been like that guy in whatever horror flick that was dies after a stiletto to the eyeball by a crazy stalker woman.

The very next night, I had a 30's male come in with an eye injury. He had a lot of bruising and swelling just under his left eyebrow. He also had some loss of his peripheral vision, and his pupils were asymmetric, and the one on the left was not quite round like it should be. Into the CT scanner he went, and there was no bleed. Ophthomology came and saw him and diagnosed him with an iris sphincter tear. As for how he injured his eye, it turned out that it happened in a strip club. Apparently, he was sitting too close to the stage, and when one of the "dancers" swung around the pole, she ended up hitting him with her heel. As you can imagine, there was a lot of chuckling about his mechanism of injury.

So maybe instead of calling them FMP's, we should call them "Don't F With Me Pumps".

Rockband

Every now and then, unique opportunities present themselves at work. This past weekend I helped staff an all-day rock concert. We worked for free (I'm sure someone got paid somewhere, but it wasn't me!), keeping the air-conditioned first-aid building a revolving door of heavily-tattooed drunk punks walking in and out. It was a rock/alternative concert, so naturally there was an all-day mosh pit that kept us busy. Paramedics on ATVs regularly brought in the vomiting and wounded.

For the most part, the patients were all drunk. There's nothing more annoying than telling a drunken fool to hold still while you stitch up their ungrateful face with a portable spotlight in a garage for lighting.

ME: "You need stitches."

DRUNK DUDE/CHICK: "I don't want stitches."

ME: "Well then, you can walk out and tomorrow wonder why your face is such a mess."

DD/C: "Fine, put them in. Ow! OW!!!! OWWWW!!!!!! I F***'N HATE GETTING STITCHES!!!"

ME: "Shut up, that was just the betadine."

There were a few serious injuries-- someone got run over by a car and another landed on his head and may have had a neck fracture. Most of the stuff was pretty simple. Our only capabilities were starting IVs and suturing. We were supposed to have been supplied with some Tylenol and Motrin, but ended up not having anything other than nebulizers for asthmatics and antiemetics. Oh well. Anyone with a loss of consciousness, possible fractures, or vague complaints that couldn't be evaluated got shipped out. A full-term pregnant woman came in actively contracting, but she wasn't actively delivering, so we shipped her out, too.

There were 12,000 concert attendants and I think we treated 78 patients. There's a formula for figuring out how many medical providers are needed to cover large-scale events. It's a pretty rough guideline though, because there's no way to really plan for large-scale pandemonium, like when a stage collapses on people or there's a fire/chemical exposure. Our coverage was exellent, and the day was relaxed enough that we took turns walking around the grounds and enjoying the bands. A mid-concert rain shower made for a lot of mud, but kept the temperature cool enough that despite all-day beer guzzling at an outdoor venue, we didn't see too much dehydration.

I stuck close to my attending on breaks because he was well-known to all of the security guys. They let us up right in front of the stage. We were behind the security guard barrier, so it was hilarious watching them catch crowd surfers all night long, and release them back to the masses. I can't imagine the workout from grabbing drunk adults and setting them down safely on the ground hour after hour.

I took these pictures with my cellphone, so they're pretty crappy, but you get the idea.

The music was great, so it made dealing with all of the drunk people worth it. The headliners were Shinedown, Seether, and Three Days Grace. We people-watched from in front of the stage for some of Shinedown and most of Three Days Grace's performance. I could hear most of Seether's songs from standing outside the medical station. Luckily, even drunk people wait through good music to seek medical treatment.

Three Days Grace:

More Three Days Grace:

I think I saw more than enough tattoos and belly flab to get me through the next year. There were a few young women who needed assistance from security getting their shirts and bikini tops back on. I gave my single guy buddy a hard time for missing out on the concert! It was entertaining just watching random shoes and water bottles flying though the air of the crowd.

duh!

So, my conclusion from today's test was that I definitely need to read more. Parts of it were good, and I think I probably misinterpreted stuff, but I still think my score will be up from last year. Maybe this was the inspirational kick in the pants that I needed to get back on track.

I cleared 8" of fresh snow off the driveway before I went in to the test this morning.

Mock Me

Sometime tomorrow, emergency medicine residents all across the country will be sitting down with #2 pencils. It's that time of year again, mock EM boards. Bleh. Luckily, our program doesn't put too much weight on your scores, but I would like to at least improve on my performance from last year (which should be pretty doable, as I set the bar REALLY low).


Most of my time this year has been in the ED, so I think I am probably at least learning things more relevant to my profession. The last two days I have been taking practice tests, which range from "duh" answers to what-the-Hell-is-that syndrome-type questions. I generally find it's not good to hear of a condition for the first time ever during testing. Judging from the way the count of tests taken on the website has been going up rapidly over the past 3-4 days, at least I know I am in the company of fellow test-crammers.


Last year it took several months before we got results back as there was a program that was caught cheating. Some programs like to use their residents' scores as bragging rights for future applicants. At my program, we just take our applicants out to drink. This year, I think I will probably have to face the music a lot sooner.